The pursuit of efficiency in medicine has elevated telehealth, now coming into its own as a viable care delivery model. It’s convenient and appeals to providers, payers, and patients alike. But for credentialing professionals, it’s challenging to achieve efficiency and quality control of telehealth providers while navigating changing regulations. Let’s explore three best practices in telehealth for credentialers.
Best practice #1: Use current credentialing terms
The advent of new technology keeps pushing the boundaries of telehealth. There’s telehealth versus telemedicine, synonyms like virtual health and e-health, and associated technologies such as artificial intelligence and mobile health (mHealth). Telemedicine typically refers to the tech and tactics used to deliver clinical care. Telehealth, meanwhile, also covers clinical uses but extends to encompass non-clinical services often the responsibility of MSPs. Such ses include remote provider training, continuing medical education, and administrative meetings.
Telehealth’s most basic terms define the physical location of participants. The “originating site” refers to the location of the patient, and the “distant site” refers to the location of the eligible healthcare provider.
The American Telemedicine Association defines two primary types of telemedicine:
- Synchronous telemedicine features a live interaction between a patient (using a smartphone, tablet, or computer with or without a camera) and a healthcare practitioner (physician or APP primary care or specialist) providing a consultation. The encounter usually occurs within a secure app the healthcare organization or a third-party provides.
- Asynchronous telemedicine is called a “store and forward” program because the encounter isn’t live but involves transfer of patient content (images, documents, videos, etc.) that the practitioner reviews and/or responds to in rendering a diagnosis.
Depending on the state and source, remote patient monitoring may be considered telehealth, which matters for regulation and reimbursement (more on these below). This mode uses devices to collect and send data to a home health agency or a remote diagnostic testing facility for interpretation. Visiting nurses often use remote patient monitoring.
Establishing what telehealth encompasses isn’t the only complex facet to this growing field. The state legislative and reimbursement structures supporting it are complicated and in transition.
Best practice #2: Check policies against changing CMS regulations and state laws
Prior to 2011, the CMS Conditions of Participation didn’t distinguish between hospital practitioners providing onsite services versus those delivering telemedicine. CMS’ final rule in 2011 streamlined credentialing and privileging for telemedicine, allowing hospitals to rely on the decisions of the distant site hospital or telemedicine entity with which they have a written agreement (meeting Medicare requirements). In ensuing years, the American Medical Association and others developed guidelines.
The telemedicine standards and requirements of NCQA, URAC, AAAHC, and HFAP do not specifically address telemedicine or telehealth. DNV GL NIAHO Acute Care Standards largely quote the CMS regulations. Joint Commission standards and CMS regulations on telehealth are lengthy and can be accessed on their respective sites.
While CMS and accreditation bodies haven’t made recent telehealth guideline updates, state-level activity has been brisk. Four key areas to watch for telehealth include states’ positions on:
- Cross-state licensing. One key source for credentialers on the state licensing front is the Interstate Medical Licensure Compact. It established a voluntary expedited pathway to licensure for qualified physicians who want to practice in multiple states.
- Prescribing medications via telehealth. There’s controversy about whether a provider has enough information to make informed decisions when all interactions with a patient have taken place remotely. Opioid and other prescription medication addictions have made prescribing laws an ever-evolving facet of telemedicine.
- What constitutes the establishment of a patient-physician relationship. All 50 states allow the provider-patient relationship to be formed via telehealth technology. However, the type of technology used varies by state. Further, it’s forced specialties to consider how to ethically incorporate telehealth into their practices—i.e., ensuring the patient’s health is the first consideration—above convenience and cost savings.
- Whether the state requires written patient informed consent. CMS doesn’t require it, but state guidelines vary. The types of items covered include informing patients about how patient confidentiality and privacy work with virtual doctor visits, the technology needed at home for a virtual visit, and what to expect in terms of scheduling, canceling, and billing for the telehealth encounter.
As additional specialties and APPs add telemedicine services, ensure that your provider management software provides access to suggested privileging criteria and links to your enrollment and reimbursement functions.
Best practice #3: Know these 10 things about telehealth reimbursement
Clinical results from telehealth are primarily positive and patients are warming up to the idea. For the business side of medicine, telehealth offers stellar growth potential. It’s not surprising that nationwide health plans (e.g., UnitedHealth, Anthem, Cigna, Aetna, Humana) have all expanded coverage and reimbursement for telehealth services and are investing heavily in marketing them.
While private and government payers still may reimburse for telehealth services at a lower rate than care delivered in-person/in-office, telemedicine’s applications seem to keep growing. For example, disaster medicine situations, growing populations of rural\underserved patients, the elderly or those with disabilities lacking transportation—all benefit from telehealth and can help hospitals’ and payers expand their reach.
The healthcare-wide expectation of increased reimbursement for telehealth likely will spur hospitals and healthcare organizations to build or expand telehealth infrastructure (e.g., technology, staff). The trickle down effect for credentialing and payer enrollment professionals will be increases in the number and types of practitioners requesting telemedicine privileges. Credentialers should know there are differences in telehealth reimbursement from private/commercial payers vs. CMS. And as with telehealth regulations and laws, the area to watch in reimbursement focuses squarely on the state legislatures.
Here are 10 telehealth reimbursement facts, followed by resources, to guide credentialing and enrollment professionals.
Private Payer Reimbursement for Telehealth
- There are 37 states with telehealth parity laws that make it mandatory for private payers to reimburse for synchronous telemedicine. More states have pending legislation for private payers.
- If the state defines telehealth/telemedicine as services provided “live” or in real time, asynchronous or store-and-forward services are often not reimbursed.
- Parity laws ensure that health plans can’t withhold reimbursement based on a patient’s location. This means that patients can do telehealth appointments from their home or office, and don’t need to travel to a qualified originating site (a cumbersome requirement for Medicare reimbursement).
- States/state medical boards decide what practitioner types can be credentialed and privileged to deliver telemedicine. However, generally any provider (e.g., MD, DO, APP) who would bill for an office visit can bill for telemedicine.
- States oversee the reimbursement amounts for telemedicine. Some require private payers to reimburse office visits and telemedicine encounters equally when the services are identical (but allow exceptions for small group plans). However, most states allow payers to set the reimbursement rates for telemedicine.
CMS Reimbursement for TelehealthAccording to Medicare guidelines, the following healthcare providers are eligible to practice telemedicine and therefore bill for these services under Medicare:
- Nurse midwives
- Clinical nurse specialists
- Clinical psychologists
- Clinical social workers
- Registered dietitians or nutrition professionals
- In April 2019, CMS finalized policies allowing Medicare Advantage plans to offer additional telehealth benefits in 2020 and beyond. Among the changes, patients can receive telehealth care and services from their homes. Previously, it was mandated that patients go to an authorized facility in an underserved area.
- Medicaid is often held to the same standards as Medicare regarding the regulation of telemedicine. However, Medicaid rules are determined on a per-state basis and can be less restrictive when it comes to reimbursement for telehealth.
- All but two states offer at least partial Medicaid reimbursement for synchronous or live video, but each state places its own restrictions on service and specialty type, and the location of participants.
- Only 15 states offer at least partial Medicaid reimbursement for asynchronous telehealth, but each state again places its own restrictions on service and specialty type, and the location of participants.
- The Center for Connected Health Policy offers a wealth of background and updates on policy.
- CMS maintains a page with wide-ranging data on telehealth—from definitations to reimbursement. It also published a complete booklet to guide Medicare fee-for-service providers.
- The Federation of State Medical Boards publishes a policy for the appropriate use of technology.
- HCPro, Inc., a division of BLR, offers a free sample policy for originating telemedicine sites.